Essential Tremor: Lesions

The treatment of medication-refractory tremor with cerebral lesioning has significantly evolved since its inception in the 1930s. While originally a highly morbid procedure, innovations in stereotactic localization and image guidance have led to several safe and efficacious methods for the surgical treatment of essential tremor. Current targets include the ventral intermediate nucleus of the thalamus and posterior subthalamic area. Radiofrequency ablation, Gamma Knife radiosurgery, and magnetic resonance-guided focused ultrasound are modern lesioning modalities in the treatment of essential tremor, and individual patient characteristics and expectations are taken into account when choosing a particular technique. The irreversibility of cerebral lesioning in the setting of current neuromodulation technology has reduced its enthusiasm; but recent advancements in transcranial procedures, patient-specific targeting, and image guidance are reinvigorating lesioning as a surgical option for tremor.